FORM 14
Financial Aid Services
P.O. Drawer 7007
Greenville, NC 27835
252-493-7339
www.pittcc.edu
2016/2017 Proof of Dependent(s) Form
Student Name: _________________________________________ PCC ID #: ______________________
This form is used to gather information for Unmarried students under the age of 24 who claim dependents on the Free Application for Federal
Student Aid (FAFSA). Dependents are those people that you will support* between July 1, 2016 and June 30, 2017. Include your children if
they get MORE THAN HALF (51%+) of their support from you or from specific support/benefits you receive FOR the children (such as
child support or Social Services, etc.) Include other people only if they meet the following criteria:
1. They live with you, and
2. They receive more than half of their support from you (51%+), and
3. They will continue to get this support from you between July 1, 2016 and June 30, 2017.
*Support includes money, housing, food, clothes, car, medical and dental care, payment of college cost and similar expenses. You cannot
count support provided by your parents.
1.
List the names and ages of your legal dependent(s) and their relationship to you the student. You must
documentation of their relationship to you (birth certificate, legal guardianship).
NAME
2.
AGE
attach legal
RELATIONSHIP
Where do the dependents named above live? (Check one answer)
______With the student in the student’s apartment or house (Attach a copy of lease or mortgage statement)
______With the student’s parent(s)
______Other: Please explain:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
3.
You (the student) live with? (Check one answer)
______With your parent(s)
______Other: Please provide the address:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
4.
What child care provisions have you made for your dependent(s) while you are in class?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
5.
Were you (the student) claimed by your parent(s) on their 2015 tax return?
Check One:
_____YES
______NO
FORM 14
Financial Aid Services
P.O. Drawer 7007
Greenville, NC 27835
252-493-7339
www.pittcc.edu
Student Name: _____________________________________________PCC ID# ___________________
6.
Were the dependent(s) named above claimed by anyone other than you (the student) on a 2015 tax return?
Check One:
_____YES
______NO
______NOT BORN until 2016 (current year)
If YES above, please list the name of the person claiming the dependent and their relationship to you.
NAME: ______________________________________________RELATIONSHIP:____________________________________
7.
Will you claim your own personal exemption on the upcoming 2016 tax return?
Check One:
______YES
______NO
8.
Who will claim the dependent(s) on the 2015 tax form? Give the individuals name and relationship to the dependent.
NAME: _______________________________________________RELATIONSHIP: ________________________________
9.
Do you or your dependents currently receive any of the following benefits? (check all that apply)
a. TANF
______YES (Attach Documentation)
______NO
b. Court ordered Child Support
______YES (Attach Documentation)
_______NO
c. Section 8 Housing
______YES (Attach Documentation)
_______NO
d. Medicaid/Private Insurance
_______YES (Attach Documentation)
_______NO
10.
Do you currently receive court ordered child support?
Check One:
______YES (Attach Documentation)
11.
______NO
List the current MONTHLY EXPENSES you incur for the following:
Housing…………………………………
Food……………………………………..
Utilities…………………………………
Clothing………………………………..
Child Care……………………………..
Medical/Dental……………………..
Transportation (gas, insurance,
Car payment, maintenance,
mass Trans)…………………………..
Other……………………………………
Your Dependent(s):
$________________
$________________
$________________
$________________
$________________
$________________
Yourself:
$_______________
$_______________
$_______________
$_______________
$_______________
$_______________
$________________
$________________
$_______________
$_______________
If you report $0.00 in any of the above categories, include a detailed explanation below as to why you have indicated no
expense for those categories and who pays for them.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
FORM 14
Financial Aid Services
P.O. Drawer 7007
Greenville, NC 27835
252-493-7339
www.pittcc.edu
12.
List the total of ALL current Monthly INCOME/SUPPORT received by the student. (You must attach supporting
Documentation.) Examples include: copy of most recent Year to Date paystub, TANF check stub, WIC eligibility notice for
your dependent(s), proof of child support paid to you, bills in your name paid by someone else, money or in-kind support
from parent(s) or other individuals.
$__________________________________
Source __________________________________
$__________________________________
Source __________________________________
$__________________________________
Source __________________________________
Certification and Signature
______ I attest that that I will provide more that half of the support for my children between July 1, 2015 and June 30, 2016.
______ I attest that the dependent(s) lived with me at the time I completed the FAFSA, will continue to live with me through the end of the
academic year, and that I will provide more than half of the support for the dependent(s) during this time. All
information provided is
complete and correct.
______ I answered incorrectly and none of these conditions apply to me. By checking this box, I understand that I will need to
return
this form to the Financial Aid Office and correct my FAFSA by changing my answer to “NO” and adding parental
information, as well as,
parental signature.
By signing this worksheet, I certify that all the information is complete, true and correct to the best of my knowledge. I understand I may be
required to provide additional information.
_____________________________________________________PCC ID#______________
Student Signature
_____________________
Date
Warning: According to the US Department of Education, if you purposely give false or misleading
information on this form, you may be subject to a fine of up to $20,000 or Imprisonment for up to 5
years OR both.